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Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviors in Hong Kong adolescents
Accepted Manuscript Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviors in Hong Kong adolescents
Jianjiu Chen, Sai Yin Ho, Man Ping Wang, Tai Hing Lam PII: DOI: Reference:
S0306-4603(18)30084-4 doi:10.1016/j.addbeh.2018.02.019 AB 5478
To appear in:
Addictive Behaviors
Received date: Revised date: Accepted date:
2 November 2017 8 February 2018 12 February 2018
Please cite this article as: Jianjiu Chen, Sai Yin Ho, Man Ping Wang, Tai Hing Lam , Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviors in Hong Kong adolescents. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ab(2017), doi:10.1016/ j.addbeh.2018.02.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviours in Hong Kong adolescents Jianjiu Chen1, MPhil; Sai Yin Ho1 * [email protected] , PhD; Man Ping Wang2, PhD; Tai Hing Lam1, MD School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China 2 School of Nursing, University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China
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Corresponding author.
ACCEPTED MANUSCRIPT Abstract Introduction We explored the role of rejection of parental smoking in the association between parental smoking and smoking in adolescents.
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Methods In a 2010-11 cross-sectional survey, 61810 Hong Kong secondary school students (mean age 14.6 years, 50.5% boys) reported their smoking (never, not susceptible; never, susceptible; ever, not current; current), paternal and maternal smoking, and whether they accepted paternal and maternal smoking (acceptance/rejection). We used multinomial logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of students’ smoking in relation to acceptance and rejection of parental smoking, compared with no parental smoking.
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Results The OR (95% CI) of “never, susceptible”, “ever, not current”, and “current”, compared with “never, not susceptible”, in relation to acceptance of paternal smoking was 1.81 (1.67-1.96), 2.46 (2.25-2.69), and 2.79 (2.51-3.10), respectively. The corresponding ORs for rejection were 0.70 (0.64-0.76), 1.23 (1.131.35), and 0.47 (0.40-0.56). The OR (95% CI) of “never, susceptible”, “ever, not current”, and “current”, compared with “never, not susceptible”, in relation to acceptance of maternal smoking was 2.05 (1.802.33), 2.57 (2.29-2.88), and 6.33 (5.39-7.44), respectively. The corresponding ORs for rejection were 0.85 (0.69-1.05), 1.59 (1.39-1.81), and 2.14 (1.71-2.68). No overlapping was observed between the 95% CIs for acceptance and rejection of paternal or maternal smoking.
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Conclusions While adolescent smoking was associated with parental smoking, especially in those who accepted parental smoking, the association was attenuated or reversed in those who rejected parental smoking.
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Keywords: adolescent smoking; smoking prevention
ACCEPTED MANUSCRIPT Introduction The association of parental smoking with smoking in adolescents is well-established (Avenevoli & Merikangas, 2003; Leonardi-Bee, Jere, & Britton, 2011), but the underlying mechanism is understudied (Avenevoli & Merikangas, 2003). Common explanations include easy access to cigarettes, imitative
T
learning, and inherited genetic susceptibility to smoking, all of which imply direct influences (Avenevoli
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& Merikangas, 2003). A few studies, however, found mediation of the association by adolescents’
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perceived smoking norms (Chen et al., 2006), general attitude towards smoking (Harakeh, Scholte, Vermulst, de Vries, & Engels, 2004), and negative outcome expectation and perceived parental approval
US
of smoking (Flay et al., 1994). These findings suggest that the association may be mediated by adolescents’ smoking-related cognition.
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We recently reported that, in a survey of Hong Kong adolescents in 2010-11, about half of those with
M
a smoking parent rejected the parent’s smoking, ie, considered it unacceptable (Chen, Ho, Wang, & Lam, 2016). In the present study, we used the survey data to explore the association between adolescent
ED
smoking and parental smoking stratified by acceptance or rejection of parental smoking, compared with no parental smoking. To our knowledge, this is the first study on how the association may vary by
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adolescents’ attitude towards parental smoking or smoking-related cognition in general. The findings may
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Methods
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help understand the underlying mechanisms and design adolescent smoking prevention programmes.
Data source
We analysed the cross-sectional survey data of 61810 students from 79 secondary schools collected in Hong Kong in 2010-11. The survey used a random sample of secondary schools stratified by the districts in Hong Kong, with school and student level response rates of 25.8% and 97.3%. Schools’ nonparticipation was mainly due to administrative reasons, and these schools were similar to the surveyed schools in district, sex composition, and medium of instruction (Chi-square tests, Ps > 0.05) (Chen et al.,
ACCEPTED MANUSCRIPT 2016). The survey was conducted in classrooms using an anonymous paper-and-pencil questionnaire. More detailed survey methods have been reported elsewhere (Leung, Ho, Wang, Lo, & Lam, 2015). Ethics approval was granted by the Institutional Review Board of the University of Hong Kong/Hospital
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Authority Hong Kong West Cluster.
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Measurements
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Students were asked in separate questions: “Do you think it is acceptable if your father/mother smokes?” with the options dichotomised as acceptance (very acceptable/acceptable) and rejection
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(unacceptable/very unacceptable) of paternal/maternal smoking. Paternal (yes/no) and maternal smoking (yes/no) were also reported.
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Students were also asked “if one of your good friends offers you a cigarette, will you smoke it?” and “do you think you will smoke cigarettes in the next 12 months?” The options for both questions were
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“definitely not”, “probably not”, “probably will”, and “definitely will”. Those choosing “definitely not”
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for both questions were deemed not susceptible to smoking, and otherwise susceptible to smoking. Students also reported whether they have ever smoked (even one puff) and whether they smoked in the
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past 30 days (current smokers). To investigate the association of interest across progressing stages of
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smoking, we derived a 4-level variable to indicate students’ smoking status: “never, not susceptible” (reference), “never, susceptible”, “ever, not current”, and “current”. Smoking susceptibility strongly
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predicts future smoking in never smoking adolescents (Choi, Gilpin, Farkas, & Pierce, 2001; Pierce, Choi, Gilpin, Farkas, & Merritt, 1996). Students also reported their sex, age (in years), perceived family affluence (relatively poor/poor to average/average/average to rich/relatively rich), and number of co-residing smokers (0/1/2/3/4/5 or more). With the numbers of co-residing people and parents who smoked, we derived a binary variable to indicate the presence of co-residing smokers other than parents (yes/no).
ACCEPTED MANUSCRIPT Analysis We used multinomial logistic regression models to estimate the odds ratios (ORs) of students’ smoking (4-level outcome variable) for study factors. We first estimated the ORs for paternal and maternal smoking (binary study factors). We then created two 3-level study factors with the levels being “no
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paternal/maternal smoking” (reference), “rejection of paternal/maternal smoking”, and “acceptance of
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paternal/maternal smoking”, and estimated the ORs for these study factors. We adjusted for maternal
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smoking in the analyses of paternal smoking, and adjusted for paternal smoking in the analyses of maternal smoking. We also adjusted for age, sex, perceived family affluence, co-residing smokers other
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than parents, and school clustering effect in all models. We used Stata 13.0 for analysis and set statistical
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significance at P < 0.05.
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Results
Table 1 shows that the sample had a mean age (standard deviation) of 14.6 (2.0) years and 50.5% were
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boys. Smoking status was as follows: “never, not susceptible” 72.6%; “never, susceptible” 10.3%; “ever,
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not current” 11.3%; and “current” 5.8%. Paternal and maternal smoking was reported by 31.0% and 5.9%. Of those with parental smoking, rejection by student was 51.3% for paternal smoking and 49.2% for
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maternal smoking.
Table 2 shows that the smoking status of “never, susceptible”, “ever, not current”, and “current”,
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compared with “never, not susceptible”, were associated with both paternal (ORs 1.14-1.73) and maternal smoking (ORs 1.35-3.88). The associations were particularly strong in those who accepted paternal (ORs 1.81-2.79) and maternal smoking (ORs 2.05-6.33). However, in those who rejected paternal smoking, the ORs were reversed for “never, susceptible” (OR 0.70, 95% CI 0.64-0.76) and “current” (OR 0.47, 0.400.56), and attenuated for “ever, not current” (OR 1.23, 1.13-1.35). In those who rejected maternal smoking, the OR was reversed only for “never, susceptible” (OR 0.85, 0.69-1.05), and attenuated for “ever, not current” (OR 1.59, 1.39-1.81) and “current” (OR 2.14, 1.71-2.68). Compared with the ORs
ACCEPTED MANUSCRIPT associated with acceptance of parental smoking, the corresponding ORs for rejection were consistently smaller. The differences were statistically significant, indicated by the non-overlapped 95% CIs. The adjusted OR of ever smoking for one or two smoking parents, compared with no smoking parent, was 1.96 (not shown in tables). In addition, 33% of students had one or two smoking parents (not shown in
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tables). These statistics suggest that 24% of smoking initiation in Hong Kong adolescents was attributable
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to parental smoking, indicating a considerable role of parental smoking in perpetuating the smoking
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population.
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Discussion
In line with the literature (Avenevoli & Merikangas, 2003; Leonardi-Bee et al., 2011), we found
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significant associations between adolescent smoking and parental smoking. The associations were
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particularly strong in the subgroups that accepted parental smoking. However, in the subgroups that rejected paternal smoking, the associations were reversed or attenuated; and in the subgroups that rejected
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maternal smoking, the associations were generally attenuated. The findings suggest that the positive effect of parental smoking on adolescent smoking may at least be ameliorated if parental smoking is rejected by
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adolescents. The inverse associations further suggest that paternal smoking, if rejected by adolescents,
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may even have opposite effects on adolescent smoking. A few qualitative studies of children and adolescents with parental smoking showed their dislike of
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secondhand smoke and concern about the health consequences of parental smoking on both their parents and themselves (Rowa-Dewar, Amos, & Cunningham-Burley, 2014; Woodgate & Kreklewetz, 2012; Woods, Springett, Porcellato, & Dugdill, 2005). In one of these studies, adolescents even claimed that parental smoking caused emotional distress and affected parent-child relationships (Woodgate & Kreklewetz, 2012). About half of Hong Kong children living with one or more smokers reported tobaccorelated unpleasant experience at home in the past 30 days (Chen, Ho, Au, Wang, & Lam, 2015). Therefore, parental smoking may cause perennial health concerns and negative experiences in adolescents
ACCEPTED MANUSCRIPT who reject their parents’ smoking. This may make these adolescents particularly anti-smoking and even less likely to smoke than those who have no smoking parents and thus have not experienced any unpleasantness caused by parental smoking. However, unlike rejection of paternal smoking, rejection of maternal smoking was not inversely
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associated with adolescent smoking. The reason for the difference is unclear. It should be noted, however,
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that Hong Kong has a strong social norm against female smoking, as is reflected by the large difference
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between the prevalence of paternal (31.0%) and maternal smoking (5.9%) in our sample. It may thus be speculated that adolescents within this context may reject maternal smoking because of their specific
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disapproval of female smoking rather than general disapproval of smoking behaviour. If so, this may have resulted in the increased risks of smoking in those who rejected maternal smoking.
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To prevent adolescent smoking, parents should ideally quit smoking or at least avoid exposing children to secondhand smoke (Chassin, Presson, Rose, Sherman, & Prost, 2002; Farkas, Distefan, Choi,
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Gilpin, & Pierce, 1999; Wang, Ho, & Lam, 2011), but quit rates in adult smokers have been low and
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parents are difficult to reach and intervene with (Messer, Trinidad, Al-Delaimy, & Pierce, 2008). Our results suggest it may be possible to mitigate the pro-smoking effects of parental smoking by intervening
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with students, who are much easier to reach in large numbers. Further research is needed to explore
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intervention strategies that promote the rejection of parental smoking directly or indirectly. We have previously reported that rejection of parental smoking was associated with being certain about the harms
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of smoking (Chen et al., 2016), which suggests that communication of the harms should be included in health education. The education may also include correction of adolescents’ potential misperceptions of smoking norms and recommendations for parents’ tobacco-related communications (Wang, Ho, Lo, & Lam, 2011). Although health education is generally considered not very effective in smoking prevention (Pierce, White, & Emery, 2012), our findings suggest that, in settings like Hong Kong, where the more effective measures such as raising tobacco taxes and banning tobacco advertisements are in place (Pierce et al., 2012), health education may play an important role in preventing adolescent smoking.
ACCEPTED MANUSCRIPT The present study is limited by its cross-sectional design, which precludes causal inferences. Prospective studies are warranted. To conclude, while adolescent smoking was associated with parental smoking, especially in those who accepted parental smoking, the association was attenuated or reversed in
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those who rejected parental smoking.
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Acknowledgements
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We thank the schools and students for participation. We also thank the Food and Health Bureau of the
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Hong Kong Government for funding this study.
Funding: This work was supported by the Food and Health Bureau of the Hong Kong Government.
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Conflict of interest declaration: None
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Role of funding sources: The Food and Health Bureau of the Hong Kong Government funded and commissioned the cross-sectional survey among Secondary 1 to 6 students. The Bureau was not involved in data collection; the data analysis or interpretation for the study presented in this manuscript; writing of the manuscript; or the decision to submit the paper for publication.
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Contributors: SYH, MPW, and THL were involved in study design. MPW collected the data. JC and SYH analysed the data. JC wrote the first draft of the manuscript, and all authors contributed to and have approved the final manuscript. Conflict of interest: All authors declare that they have no conflicts of interest.
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Acknowledgements: We sincerely thank the schools and students for participation.
References
Avenevoli, S., & Merikangas, K. R. (2003). Familial influences on adolescent smoking. Addiction, 98(s1), 1-20. Chassin, L., Presson, C., Rose, J., Sherman, S. J., & Prost, J. (2002). Parental smoking cessation and adolescent smoking. Journal of Pediatric Psychology, 27(6), 485-496. Chen, J. J., Ho, S. Y., Au, W. M., Wang, M. P., & Lam, T. H. (2015). Family Smoking, Exposure to Secondhand Smoke at Home and Family Unhappiness in Children. International Journal of Environmental Research and Public Health, 12(11), 14557-14570. Chen, J. J., Ho, S. Y., Wang, M. P., & Lam, T. H. (2016). Negative perceptions of parental smoking among 61810 Hong Kong adolescents: A cross sectional school based survey. Tobacco Prevention and Cessation, 2, 71.
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Chen, X., Stanton, B., Fang, X., Li, X., Lin, D., Zhang, J., et al. (2006). Perceived smoking norms, socioenvironmental factors, personal attitudes and adolescent smoking in China: a mediation analysis with longitudinal data. Journal of Adolescent Health, 38(4), 359-368. Choi, W. S., Gilpin, E. A., Farkas, A. J., & Pierce, J. P. (2001). Determining the probability of future smoking among adolescents. Addiction, 96(2), 313-323. Farkas, A. J., Distefan, J. M., Choi, W. S., Gilpin, E. A., & Pierce, J. P. (1999). Does parental smoking cessation discourage adolescent smoking? Preventive Medicine, 28(3), 213-218. Flay, B. R., Hu, F. B., Siddiqui, O., Day, L. E., Hedeker, D., Petraitis, J., et al. (1994). Differential influence of parental smoking and friends' smoking on adolescent initiation and escalation and smoking. Journal of Health and Social Behavior, 35(3), 248-265. Harakeh, Z., Scholte, R. H., Vermulst, A. A., de Vries, H., & Engels, R. C. (2004). Parental factors and adolescents' smoking behavior: an extension of the theory of planned behavior. Preventive Medicine, 39(5), 951-961. Leonardi-Bee, J., Jere, M. L., & Britton, J. (2011). Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: a systematic review and meta-analysis. Thorax, 66(10), 847-855. Leung, L. T., Ho, S. Y., Wang, M. P., Lo, W. S., & Lam, T. H. (2015). Exposure to secondhand smoke from neighbours and respiratory symptoms in never-smoking adolescents in Hong Kong: a crosssectional study. BMJ Open, 5(11), e008607. Messer, K., Trinidad, D. R., Al-Delaimy, W. K., & Pierce, J. P. (2008). Smoking cessation rates in the United States: a comparison of young adult and older smokers. American Journal of Public Health, 98(2), 317-322. Pierce, J. P., Choi, W. S., Gilpin, E. A., Farkas, A. J., & Merritt, R. K. (1996). Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology, 15(5), 355. Pierce, J. P., White, V. M., & Emery, S. L. (2012). What public health strategies are needed to reduce smoking initiation? Tobacco Control, 21(2), 258-264. Rowa-Dewar, N., Amos, A., & Cunningham-Burley, S. (2014). Children's resistance to parents' smoking in the home and car: a qualitative study. Addiction, 109(4), 645-652. Wang, M. P., Ho, S. Y., & Lam, T. H. (2011). Parental smoking, exposure to secondhand smoke at home, and smoking initiation among young children. Nicotine & Tobacco Research, 13(9), 827-832. Wang, M. P., Ho, S. Y., Lo, W. S., & Lam, T. H. (2011). Overestimation of peer smoking prevalence predicts smoking initiation among primary school students in Hong Kong. Journal of Adolescent Health, 48(4), 418-420. Woodgate, R. L., & Kreklewetz, C. M. (2012). Youth’s narratives about family members smoking: parenting the parent-it’s not fair! BMC Public Health, 12(1), 1. Woods, S. E., Springett, J., Porcellato, L., & Dugdill, L. (2005). ‘Stop it, it's bad for you and me’: experiences of and views on passive smoking among primary-school children in Liverpool. Health Education Research, 20(6), 645-655.
ACCEPTED MANUSCRIPT Table 1. Basic characteristics of the sample. N (%)a 30585 (49.5) 31225 (50.5) 14.6 (2.0)
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4933 (8.0) 15269 (24.8) 33175 (53.8) 6988 (11.3) 1318 (2.1)
Number and proportion unless otherwise stated.
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Sex Girls Boys Mean age in years (standard deviation) Perceived family affluence Relatively rich Average to rich Average Poor to average Relatively poor Co-residing smoker(s) other than parents No Yes Attitude towards paternal smoking (among those with paternal smoking) Acceptance Rejection Attitude towards maternal smoking (among those with maternal smoking) Acceptance Rejection Paternal smoking No Yes Maternal smoking No Yes Smoking status Never, not susceptible Never, susceptible Ever, not current Current
54723 (89.0) 6762 (11.0)
9317 (48.7) 9830 (51.3)
1865 (50.8) 1807 (49.2) 42620 (69.0) 19147 (31.0) 58126 (94.1) 3672 (5.9) 44722 (72.6) 6315 (10.3) 6963 (11.3) 3598 (5.8)
ACCEPTED MANUSCRIPT Table 2. Adjusted odds ratios (95% confidence intervals) a of adolescent smoking (4-level variable) related to parental smoking, and related to rejection and acceptance of parental smoking. Never, not susceptible (reference group) Never, susceptible Ever, not current Current Paternal smoking No Yes
Rejection Acceptance
1 0.70 (0.64,0.76) *** 1.81 (1.67,1.96) ***
1 1.23 (1.13,1.35) *** 2.46 (2.25,2.69) ***
Maternal smoking No Yes
1 1.35 (1.21,1.51) ***
Attitude towards maternal smoking Rejection Acceptance
1 0.85 (0.69,1.05) 2.05 (1.80,2.33) ***
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*p < .05; **p < .01; ***p < .001. a
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Attitude towards paternal smoking
1 2.01 (1.82,2.21) ***
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Maternal smoking No Yes Yes
1 1.73 (1.60,1.87) ***
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Paternal smoking No Yes Yes
1 1.14 (1.07,1.22) ***
1 1.59 (1.39,1.81) *** 2.57 (2.29,2.88) ***
1 1.44 (1.31,1.58) ***
1 0.47 (0.40,0.56) *** 2.79 (2.51,3.10) ***
1 3.88 (3.32,4.53) ***
1 2.14 (1.71,2.68) *** 6.33 (5.39,7.44) ***
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All analyses were adjusted for age, sex, perceived family affluence, co-residing smokers other than parents, and school clustering effect. In addition, analyses of paternal smoking were adjusted for maternal smoking, and vice versa.
ACCEPTED MANUSCRIPT Highlights
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Parental smoking was associated with increased risks of adolescent smoking. The increase was weakened or reversed in those who rejected their parent’s smoking. Adolescents’ rejection of parental smoking may mitigate its pro-smoking effects.
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Jianjiu Chen, Sai Yin Ho, Man Ping Wang, Tai Hing Lam PII: DOI: Reference:
S0306-4603(18)30084-4 doi:10.1016/j.addbeh.2018.02.019 AB 5478
To appear in:
Addictive Behaviors
Received date: Revised date: Accepted date:
2 November 2017 8 February 2018 12 February 2018
Please cite this article as: Jianjiu Chen, Sai Yin Ho, Man Ping Wang, Tai Hing Lam , Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviors in Hong Kong adolescents. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ab(2017), doi:10.1016/ j.addbeh.2018.02.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviours in Hong Kong adolescents Jianjiu Chen1, MPhil; Sai Yin Ho1 * [email protected] , PhD; Man Ping Wang2, PhD; Tai Hing Lam1, MD School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China 2 School of Nursing, University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China
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1
*
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M
AN
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Corresponding author.
ACCEPTED MANUSCRIPT Abstract Introduction We explored the role of rejection of parental smoking in the association between parental smoking and smoking in adolescents.
CR
IP
T
Methods In a 2010-11 cross-sectional survey, 61810 Hong Kong secondary school students (mean age 14.6 years, 50.5% boys) reported their smoking (never, not susceptible; never, susceptible; ever, not current; current), paternal and maternal smoking, and whether they accepted paternal and maternal smoking (acceptance/rejection). We used multinomial logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of students’ smoking in relation to acceptance and rejection of parental smoking, compared with no parental smoking.
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M
AN
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Results The OR (95% CI) of “never, susceptible”, “ever, not current”, and “current”, compared with “never, not susceptible”, in relation to acceptance of paternal smoking was 1.81 (1.67-1.96), 2.46 (2.25-2.69), and 2.79 (2.51-3.10), respectively. The corresponding ORs for rejection were 0.70 (0.64-0.76), 1.23 (1.131.35), and 0.47 (0.40-0.56). The OR (95% CI) of “never, susceptible”, “ever, not current”, and “current”, compared with “never, not susceptible”, in relation to acceptance of maternal smoking was 2.05 (1.802.33), 2.57 (2.29-2.88), and 6.33 (5.39-7.44), respectively. The corresponding ORs for rejection were 0.85 (0.69-1.05), 1.59 (1.39-1.81), and 2.14 (1.71-2.68). No overlapping was observed between the 95% CIs for acceptance and rejection of paternal or maternal smoking.
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Conclusions While adolescent smoking was associated with parental smoking, especially in those who accepted parental smoking, the association was attenuated or reversed in those who rejected parental smoking.
AC
CE
Keywords: adolescent smoking; smoking prevention
ACCEPTED MANUSCRIPT Introduction The association of parental smoking with smoking in adolescents is well-established (Avenevoli & Merikangas, 2003; Leonardi-Bee, Jere, & Britton, 2011), but the underlying mechanism is understudied (Avenevoli & Merikangas, 2003). Common explanations include easy access to cigarettes, imitative
T
learning, and inherited genetic susceptibility to smoking, all of which imply direct influences (Avenevoli
IP
& Merikangas, 2003). A few studies, however, found mediation of the association by adolescents’
CR
perceived smoking norms (Chen et al., 2006), general attitude towards smoking (Harakeh, Scholte, Vermulst, de Vries, & Engels, 2004), and negative outcome expectation and perceived parental approval
US
of smoking (Flay et al., 1994). These findings suggest that the association may be mediated by adolescents’ smoking-related cognition.
AN
We recently reported that, in a survey of Hong Kong adolescents in 2010-11, about half of those with
M
a smoking parent rejected the parent’s smoking, ie, considered it unacceptable (Chen, Ho, Wang, & Lam, 2016). In the present study, we used the survey data to explore the association between adolescent
ED
smoking and parental smoking stratified by acceptance or rejection of parental smoking, compared with no parental smoking. To our knowledge, this is the first study on how the association may vary by
PT
adolescents’ attitude towards parental smoking or smoking-related cognition in general. The findings may
AC
Methods
CE
help understand the underlying mechanisms and design adolescent smoking prevention programmes.
Data source
We analysed the cross-sectional survey data of 61810 students from 79 secondary schools collected in Hong Kong in 2010-11. The survey used a random sample of secondary schools stratified by the districts in Hong Kong, with school and student level response rates of 25.8% and 97.3%. Schools’ nonparticipation was mainly due to administrative reasons, and these schools were similar to the surveyed schools in district, sex composition, and medium of instruction (Chi-square tests, Ps > 0.05) (Chen et al.,
ACCEPTED MANUSCRIPT 2016). The survey was conducted in classrooms using an anonymous paper-and-pencil questionnaire. More detailed survey methods have been reported elsewhere (Leung, Ho, Wang, Lo, & Lam, 2015). Ethics approval was granted by the Institutional Review Board of the University of Hong Kong/Hospital
T
Authority Hong Kong West Cluster.
IP
Measurements
CR
Students were asked in separate questions: “Do you think it is acceptable if your father/mother smokes?” with the options dichotomised as acceptance (very acceptable/acceptable) and rejection
US
(unacceptable/very unacceptable) of paternal/maternal smoking. Paternal (yes/no) and maternal smoking (yes/no) were also reported.
AN
Students were also asked “if one of your good friends offers you a cigarette, will you smoke it?” and “do you think you will smoke cigarettes in the next 12 months?” The options for both questions were
M
“definitely not”, “probably not”, “probably will”, and “definitely will”. Those choosing “definitely not”
ED
for both questions were deemed not susceptible to smoking, and otherwise susceptible to smoking. Students also reported whether they have ever smoked (even one puff) and whether they smoked in the
PT
past 30 days (current smokers). To investigate the association of interest across progressing stages of
CE
smoking, we derived a 4-level variable to indicate students’ smoking status: “never, not susceptible” (reference), “never, susceptible”, “ever, not current”, and “current”. Smoking susceptibility strongly
AC
predicts future smoking in never smoking adolescents (Choi, Gilpin, Farkas, & Pierce, 2001; Pierce, Choi, Gilpin, Farkas, & Merritt, 1996). Students also reported their sex, age (in years), perceived family affluence (relatively poor/poor to average/average/average to rich/relatively rich), and number of co-residing smokers (0/1/2/3/4/5 or more). With the numbers of co-residing people and parents who smoked, we derived a binary variable to indicate the presence of co-residing smokers other than parents (yes/no).
ACCEPTED MANUSCRIPT Analysis We used multinomial logistic regression models to estimate the odds ratios (ORs) of students’ smoking (4-level outcome variable) for study factors. We first estimated the ORs for paternal and maternal smoking (binary study factors). We then created two 3-level study factors with the levels being “no
T
paternal/maternal smoking” (reference), “rejection of paternal/maternal smoking”, and “acceptance of
IP
paternal/maternal smoking”, and estimated the ORs for these study factors. We adjusted for maternal
CR
smoking in the analyses of paternal smoking, and adjusted for paternal smoking in the analyses of maternal smoking. We also adjusted for age, sex, perceived family affluence, co-residing smokers other
US
than parents, and school clustering effect in all models. We used Stata 13.0 for analysis and set statistical
AN
significance at P < 0.05.
M
Results
Table 1 shows that the sample had a mean age (standard deviation) of 14.6 (2.0) years and 50.5% were
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boys. Smoking status was as follows: “never, not susceptible” 72.6%; “never, susceptible” 10.3%; “ever,
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not current” 11.3%; and “current” 5.8%. Paternal and maternal smoking was reported by 31.0% and 5.9%. Of those with parental smoking, rejection by student was 51.3% for paternal smoking and 49.2% for
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maternal smoking.
Table 2 shows that the smoking status of “never, susceptible”, “ever, not current”, and “current”,
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compared with “never, not susceptible”, were associated with both paternal (ORs 1.14-1.73) and maternal smoking (ORs 1.35-3.88). The associations were particularly strong in those who accepted paternal (ORs 1.81-2.79) and maternal smoking (ORs 2.05-6.33). However, in those who rejected paternal smoking, the ORs were reversed for “never, susceptible” (OR 0.70, 95% CI 0.64-0.76) and “current” (OR 0.47, 0.400.56), and attenuated for “ever, not current” (OR 1.23, 1.13-1.35). In those who rejected maternal smoking, the OR was reversed only for “never, susceptible” (OR 0.85, 0.69-1.05), and attenuated for “ever, not current” (OR 1.59, 1.39-1.81) and “current” (OR 2.14, 1.71-2.68). Compared with the ORs
ACCEPTED MANUSCRIPT associated with acceptance of parental smoking, the corresponding ORs for rejection were consistently smaller. The differences were statistically significant, indicated by the non-overlapped 95% CIs. The adjusted OR of ever smoking for one or two smoking parents, compared with no smoking parent, was 1.96 (not shown in tables). In addition, 33% of students had one or two smoking parents (not shown in
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tables). These statistics suggest that 24% of smoking initiation in Hong Kong adolescents was attributable
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to parental smoking, indicating a considerable role of parental smoking in perpetuating the smoking
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population.
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Discussion
In line with the literature (Avenevoli & Merikangas, 2003; Leonardi-Bee et al., 2011), we found
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significant associations between adolescent smoking and parental smoking. The associations were
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particularly strong in the subgroups that accepted parental smoking. However, in the subgroups that rejected paternal smoking, the associations were reversed or attenuated; and in the subgroups that rejected
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maternal smoking, the associations were generally attenuated. The findings suggest that the positive effect of parental smoking on adolescent smoking may at least be ameliorated if parental smoking is rejected by
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adolescents. The inverse associations further suggest that paternal smoking, if rejected by adolescents,
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may even have opposite effects on adolescent smoking. A few qualitative studies of children and adolescents with parental smoking showed their dislike of
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secondhand smoke and concern about the health consequences of parental smoking on both their parents and themselves (Rowa-Dewar, Amos, & Cunningham-Burley, 2014; Woodgate & Kreklewetz, 2012; Woods, Springett, Porcellato, & Dugdill, 2005). In one of these studies, adolescents even claimed that parental smoking caused emotional distress and affected parent-child relationships (Woodgate & Kreklewetz, 2012). About half of Hong Kong children living with one or more smokers reported tobaccorelated unpleasant experience at home in the past 30 days (Chen, Ho, Au, Wang, & Lam, 2015). Therefore, parental smoking may cause perennial health concerns and negative experiences in adolescents
ACCEPTED MANUSCRIPT who reject their parents’ smoking. This may make these adolescents particularly anti-smoking and even less likely to smoke than those who have no smoking parents and thus have not experienced any unpleasantness caused by parental smoking. However, unlike rejection of paternal smoking, rejection of maternal smoking was not inversely
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associated with adolescent smoking. The reason for the difference is unclear. It should be noted, however,
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that Hong Kong has a strong social norm against female smoking, as is reflected by the large difference
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between the prevalence of paternal (31.0%) and maternal smoking (5.9%) in our sample. It may thus be speculated that adolescents within this context may reject maternal smoking because of their specific
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disapproval of female smoking rather than general disapproval of smoking behaviour. If so, this may have resulted in the increased risks of smoking in those who rejected maternal smoking.
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To prevent adolescent smoking, parents should ideally quit smoking or at least avoid exposing children to secondhand smoke (Chassin, Presson, Rose, Sherman, & Prost, 2002; Farkas, Distefan, Choi,
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Gilpin, & Pierce, 1999; Wang, Ho, & Lam, 2011), but quit rates in adult smokers have been low and
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parents are difficult to reach and intervene with (Messer, Trinidad, Al-Delaimy, & Pierce, 2008). Our results suggest it may be possible to mitigate the pro-smoking effects of parental smoking by intervening
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with students, who are much easier to reach in large numbers. Further research is needed to explore
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intervention strategies that promote the rejection of parental smoking directly or indirectly. We have previously reported that rejection of parental smoking was associated with being certain about the harms
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of smoking (Chen et al., 2016), which suggests that communication of the harms should be included in health education. The education may also include correction of adolescents’ potential misperceptions of smoking norms and recommendations for parents’ tobacco-related communications (Wang, Ho, Lo, & Lam, 2011). Although health education is generally considered not very effective in smoking prevention (Pierce, White, & Emery, 2012), our findings suggest that, in settings like Hong Kong, where the more effective measures such as raising tobacco taxes and banning tobacco advertisements are in place (Pierce et al., 2012), health education may play an important role in preventing adolescent smoking.
ACCEPTED MANUSCRIPT The present study is limited by its cross-sectional design, which precludes causal inferences. Prospective studies are warranted. To conclude, while adolescent smoking was associated with parental smoking, especially in those who accepted parental smoking, the association was attenuated or reversed in
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those who rejected parental smoking.
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Acknowledgements
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We thank the schools and students for participation. We also thank the Food and Health Bureau of the
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Hong Kong Government for funding this study.
Funding: This work was supported by the Food and Health Bureau of the Hong Kong Government.
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Conflict of interest declaration: None
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Role of funding sources: The Food and Health Bureau of the Hong Kong Government funded and commissioned the cross-sectional survey among Secondary 1 to 6 students. The Bureau was not involved in data collection; the data analysis or interpretation for the study presented in this manuscript; writing of the manuscript; or the decision to submit the paper for publication.
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Contributors: SYH, MPW, and THL were involved in study design. MPW collected the data. JC and SYH analysed the data. JC wrote the first draft of the manuscript, and all authors contributed to and have approved the final manuscript. Conflict of interest: All authors declare that they have no conflicts of interest.
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Acknowledgements: We sincerely thank the schools and students for participation.
References
Avenevoli, S., & Merikangas, K. R. (2003). Familial influences on adolescent smoking. Addiction, 98(s1), 1-20. Chassin, L., Presson, C., Rose, J., Sherman, S. J., & Prost, J. (2002). Parental smoking cessation and adolescent smoking. Journal of Pediatric Psychology, 27(6), 485-496. Chen, J. J., Ho, S. Y., Au, W. M., Wang, M. P., & Lam, T. H. (2015). Family Smoking, Exposure to Secondhand Smoke at Home and Family Unhappiness in Children. International Journal of Environmental Research and Public Health, 12(11), 14557-14570. Chen, J. J., Ho, S. Y., Wang, M. P., & Lam, T. H. (2016). Negative perceptions of parental smoking among 61810 Hong Kong adolescents: A cross sectional school based survey. Tobacco Prevention and Cessation, 2, 71.
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Chen, X., Stanton, B., Fang, X., Li, X., Lin, D., Zhang, J., et al. (2006). Perceived smoking norms, socioenvironmental factors, personal attitudes and adolescent smoking in China: a mediation analysis with longitudinal data. Journal of Adolescent Health, 38(4), 359-368. Choi, W. S., Gilpin, E. A., Farkas, A. J., & Pierce, J. P. (2001). Determining the probability of future smoking among adolescents. Addiction, 96(2), 313-323. Farkas, A. J., Distefan, J. M., Choi, W. S., Gilpin, E. A., & Pierce, J. P. (1999). Does parental smoking cessation discourage adolescent smoking? Preventive Medicine, 28(3), 213-218. Flay, B. R., Hu, F. B., Siddiqui, O., Day, L. E., Hedeker, D., Petraitis, J., et al. (1994). Differential influence of parental smoking and friends' smoking on adolescent initiation and escalation and smoking. Journal of Health and Social Behavior, 35(3), 248-265. Harakeh, Z., Scholte, R. H., Vermulst, A. A., de Vries, H., & Engels, R. C. (2004). Parental factors and adolescents' smoking behavior: an extension of the theory of planned behavior. Preventive Medicine, 39(5), 951-961. Leonardi-Bee, J., Jere, M. L., & Britton, J. (2011). Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: a systematic review and meta-analysis. Thorax, 66(10), 847-855. Leung, L. T., Ho, S. Y., Wang, M. P., Lo, W. S., & Lam, T. H. (2015). Exposure to secondhand smoke from neighbours and respiratory symptoms in never-smoking adolescents in Hong Kong: a crosssectional study. BMJ Open, 5(11), e008607. Messer, K., Trinidad, D. R., Al-Delaimy, W. K., & Pierce, J. P. (2008). Smoking cessation rates in the United States: a comparison of young adult and older smokers. American Journal of Public Health, 98(2), 317-322. Pierce, J. P., Choi, W. S., Gilpin, E. A., Farkas, A. J., & Merritt, R. K. (1996). Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology, 15(5), 355. Pierce, J. P., White, V. M., & Emery, S. L. (2012). What public health strategies are needed to reduce smoking initiation? Tobacco Control, 21(2), 258-264. Rowa-Dewar, N., Amos, A., & Cunningham-Burley, S. (2014). Children's resistance to parents' smoking in the home and car: a qualitative study. Addiction, 109(4), 645-652. Wang, M. P., Ho, S. Y., & Lam, T. H. (2011). Parental smoking, exposure to secondhand smoke at home, and smoking initiation among young children. Nicotine & Tobacco Research, 13(9), 827-832. Wang, M. P., Ho, S. Y., Lo, W. S., & Lam, T. H. (2011). Overestimation of peer smoking prevalence predicts smoking initiation among primary school students in Hong Kong. Journal of Adolescent Health, 48(4), 418-420. Woodgate, R. L., & Kreklewetz, C. M. (2012). Youth’s narratives about family members smoking: parenting the parent-it’s not fair! BMC Public Health, 12(1), 1. Woods, S. E., Springett, J., Porcellato, L., & Dugdill, L. (2005). ‘Stop it, it's bad for you and me’: experiences of and views on passive smoking among primary-school children in Liverpool. Health Education Research, 20(6), 645-655.
ACCEPTED MANUSCRIPT Table 1. Basic characteristics of the sample. N (%)a 30585 (49.5) 31225 (50.5) 14.6 (2.0)
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4933 (8.0) 15269 (24.8) 33175 (53.8) 6988 (11.3) 1318 (2.1)
Number and proportion unless otherwise stated.
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Sex Girls Boys Mean age in years (standard deviation) Perceived family affluence Relatively rich Average to rich Average Poor to average Relatively poor Co-residing smoker(s) other than parents No Yes Attitude towards paternal smoking (among those with paternal smoking) Acceptance Rejection Attitude towards maternal smoking (among those with maternal smoking) Acceptance Rejection Paternal smoking No Yes Maternal smoking No Yes Smoking status Never, not susceptible Never, susceptible Ever, not current Current
54723 (89.0) 6762 (11.0)
9317 (48.7) 9830 (51.3)
1865 (50.8) 1807 (49.2) 42620 (69.0) 19147 (31.0) 58126 (94.1) 3672 (5.9) 44722 (72.6) 6315 (10.3) 6963 (11.3) 3598 (5.8)
ACCEPTED MANUSCRIPT Table 2. Adjusted odds ratios (95% confidence intervals) a of adolescent smoking (4-level variable) related to parental smoking, and related to rejection and acceptance of parental smoking. Never, not susceptible (reference group) Never, susceptible Ever, not current Current Paternal smoking No Yes
Rejection Acceptance
1 0.70 (0.64,0.76) *** 1.81 (1.67,1.96) ***
1 1.23 (1.13,1.35) *** 2.46 (2.25,2.69) ***
Maternal smoking No Yes
1 1.35 (1.21,1.51) ***
Attitude towards maternal smoking Rejection Acceptance
1 0.85 (0.69,1.05) 2.05 (1.80,2.33) ***
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*p < .05; **p < .01; ***p < .001. a
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Attitude towards paternal smoking
1 2.01 (1.82,2.21) ***
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Maternal smoking No Yes Yes
1 1.73 (1.60,1.87) ***
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Paternal smoking No Yes Yes
1 1.14 (1.07,1.22) ***
1 1.59 (1.39,1.81) *** 2.57 (2.29,2.88) ***
1 1.44 (1.31,1.58) ***
1 0.47 (0.40,0.56) *** 2.79 (2.51,3.10) ***
1 3.88 (3.32,4.53) ***
1 2.14 (1.71,2.68) *** 6.33 (5.39,7.44) ***
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All analyses were adjusted for age, sex, perceived family affluence, co-residing smokers other than parents, and school clustering effect. In addition, analyses of paternal smoking were adjusted for maternal smoking, and vice versa.
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Parental smoking was associated with increased risks of adolescent smoking. The increase was weakened or reversed in those who rejected their parent’s smoking. Adolescents’ rejection of parental smoking may mitigate its pro-smoking effects.
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